Saturday, January 2, 2010

Remote Area Medical expeditions provide free health care to those who cannot afford to pay for it.

In the January 2, 2010 article "Lessons of a weekend of free health care," Associated Press national writer Adam Geller reports on a Remote Area Medical (RAM) expedition to provide medical services to those in need.
MAYNARDVILLE, Tenn. – The two-hour drive is done, but Hannah and Jack Hurst leave the Honda's engine running.

Hannah's prayers have brought them here. Now there's little to do but turn up the car's heat, try to get some sleep and wait for morning — and a set of glass and metal doors to open.

Still, Hannah doesn't complain. The 26-year-old mother of three has waited "pretty much as long as I can remember" to escape the pain throbbing through her jaws. Jack lost his road construction job a year ago and health insurance is out of the question. If the answer to Hannah's misery can be found behind those doors, then what's 10 hours more?

Out in the dark, the Hursts have plenty of company. Even before 10 p.m. on Friday in late fall, nearly 50 cars ring the ball field parking lot. By 6 a.m. Saturday, more than 400 men and women — some wrapped in blankets, others leaning on walkers — stand tightlipped and bleary-eyed under the Big Dipper.

They clutch numbered tickets, ready to claim the prize for perseverance: By day's end, as long as they can keep appetites and tempers in check and the sleep from their eyes, they will win the privilege of care from a dentist or a doctor.

In a country convulsed over health care, the scene would be alarming if it wasn't so predictable.

In fact, it's always the same, Stan Brock says. For 17 years, Brock has piloted a nonprofit called Remote Area Medical around the country, commandeering high school gyms and county fairgrounds to offer free health care to the uninsured, the underinsured and the desperate.

Brock has seen so many crowds like the one massed outside Union County High School this dawn he chides himself for losing track of whether this is RAM's 578th expedition or its 587th (it's the latter). And yet in every one of those seemingly identical crowds there are hundreds of Hannah Hursts, each a unique testament to the nation's ragged pursuit of health care answers.

Over the next two days, RAM's volunteers will examine, test, anesthetize, extract and prescribe hundreds of solutions for individual aches and afflictions. They will, in the few moments left, try to convince patients they'll probably never see again of the virtues of healthier living and continuous care. They will do their best to answer Hannah Hurst's prayers.

It's pretty clear lawmakers debating reform in the nation's capital could learn something here in the trenches.

But the most striking lesson might also be the most daunting: To fix the nation's health care inequities, expanding health insurance alone may not be enough.

"OK. Good morning folks," Brock booms in an accent crisp with authority. "We're going to get started on time."

It is precisely 6 a.m., and Brock has just pushed open the high school's doors, stepping out in to 45-degree darkness and a gathering sea of faces. He has questions ready for mornings like this. But he already knows what the answers will be.

"Who's here to see a dentist?"

More than half raise their hands. Who has come to see an eye doctor? Almost as many. Who's here to see a medical doctor? Scattered hands go up, but Brock, smilingly sagely, expects that, too.

"Really, they all need to see a doctor," he says. "They just don't want to lose their place on line."

Back at 3:30 a.m., the Tennessee State Guard had passed out tickets to those waiting for care. No two of their stories are the same.

Ronnie and Debbie Erwin have driven 2 1/2 hours from Johnson City. Insurance from her job at a telecommunications company covers his care for spinal stenosis. But the prescriptions caused his teeth to disintegrate and infection followed. Insurance doesn't cover that.

"My doctor said you've got to do something or it's going to kill you," Ronnie says.

Melissa Hayes, a $7-an-hour home health aide from nearby Luttrell, has waited in the car since 11:30 p.m. with her daughters, aged 5, 7 and 10. Hayes has a short list of needs for RAM. But first is getting the oldest, Brittney Prince, in to an eye doctor. The fifth grader can't see the board at school, but the family doesn't have money for eyeglasses.

Joe Mason is anxious to do something about a molar that broke more than six months ago. To limit the pain, he's been chewing on the right side of his mouth ever since. But if there's time, he's thinking about seeing a doctor, too.

The idea, though, leaves him uncertain.

"How do you go in there and talk to a doctor? I probably haven't been to one in 20 years," says Mason, 31.

"I mean, what are you supposed to say to one?"

"Who's got No. 1?"

The day's first patients are waved in to "triage" — otherwise known as the high school cafeteria — and nurses at the lunch tables cuff them for blood pressure readings.

Decide which of your needs is today's priority, volunteers urge. There won't be enough time or doctors to deal with them all.

"Dental?" Go to the gym.

"General medical?" Past the vending machines to the classrooms down the hall.

Compared with many of RAM's expeditions, the volunteers did not have to travel far — it took less than an hour for the trucks to reach Maynardville. But this is only the most recent stop on a long and convoluted journey that began in the Amazon.

Brock, a British boarding school dropout, landed there more than 50 years ago and turned himself into a South American cowboy. He left the rain forest in the 1960s to wrestle anacondas and rope giraffes on a popular U.S. television show, "Wild Kingdom."

But in 1985, settled in Knoxville, Tenn., he began organizing medical relief flights back to the region, where it otherwise takes 26 days on foot to reach a doctor.

Seven years later, he got a call. The only hospital in Hancock County, Tenn., had closed and the sole dentist had moved away.

"We literally loaded a couple of 400-pound dental chairs that we borrowed into the back of a pickup truck and we went up there with a couple of dentists," Brock says. "It wasn't long before another county called and on and on and on and on."

Hundreds of expeditions later, RAM hasn't abandoned the Amazon. But Americans have become the group's main mission, especially people struggling to get by in the mountain towns of Tennessee, Virginia and Kentucky.

At a RAM expedition a few weeks back in Winchester, Tenn., a man who came in for dental work complained of paralysis in one leg — a sign of a stroke. But he rejected paramedics' coaxing to go to the hospital, saying he couldn't afford it. Last year, in Wise, Va., an optometrist peering into a man's pupils diagnosed a brain tumor.

For all their planning, RAM's people never know entirely what to expect. Neither do their patients.

Although Hannah and Jack Hurst got to Maynardville early, they lost their place in line when the parking lot was cleared by police responding to shots from nearby woods — just some teenagers hunting, as it turns out.

By the time Hannah's ticket — number 156 — is called and the couple reaches the gym, visitors in scrubs have the run of the Union County Patriots' home court.

Blue tarps blanket the hardwood. Four rows of dentists, hygienists, and dental students from as far as Buffalo, N.Y., cluster around 38 portable dental chairs, wielding suction hoses and extracting forceps. Aside from the patients packing the bleachers, it looks like a scene from "M-A-S-H."

Finally, Hannah Hurst is called to a chair and explains why she's come.

In pregnancy, her mother suffered from a calcium deficiency. Hannah's baby teeth decayed fast. It was even worse with her permanent teeth and disease filled her gums, swelled with abscesses. When her parents had insurance, it either wasn't enough or dental wasn't covered. They set aside money, but always fell short. Four years ago, Hannah saved enough to reach a dentist's chair, when her cell phone rang. Her aunt, hospitalized with cancer, had taken a turn for the worse. She rushed out and never went back, even though a spring breeze can trigger pain that knocks her to her knees.

Back home in Campbell County, worshippers at Sled Creek Holiness Community Church have prayed, even fasted, to help Hannah heal.

Today Hannah — holding tight to Jack's hand as she lies back in the dental chair — is ready to embrace the answer.

Please, she asks, pull them all out.

Most of those waiting for a dentist or an eye exam have a need that can't wait. It's calmer in the three classrooms reserved for the medical doctors, but the patients' stories are at least as telling.

"I went to college. I'm a graduate. I just never thought I'd ever be here," Earleen Black says.

Until losing her job eight months ago, Black was a radiology technologist at a hospital. She's embarrassed to ask for help. Maynardville — the center of a county of 19,000, set between corduroy ridges 45 minutes from Knoxville — is a small town and she knows so many people.

But Black needs to find work. Instead, she's preoccupied with bursitis that's attacked with the force of a baseball bat. With insurance, a yearly steroid shot provided an easy answer. Now it's $200 she doesn't have. She's relieved when a doctor administers the shot without charge, but mystified that there was almost no wait.

"I'm surprised they're not more people begging at the door," Black says.

The truth is many here to see a doctor didn't want to come. They were sent by one of RAM's volunteer nurses because their blood pressure registered too high to undergo the dentist's drill.

To some, though, that is just a temporary setback.

Daniel Drake's blood pressure came in at an eye-popping 200/120. He chalks it up to lack of sleep and an energy drink, and leaves happy when a pill brings it down enough to get his tooth fixed. But Dr. Alan Weder, a University of Michigan researcher volunteering for the weekend, shakes his head with concern.

"If that's the way he's walking around, his risk of having a heart attack or a stroke in the next five years is probably 20 to 30 percent," Weder says. "And that's for want of 30 cents in medicine."

As doctors ask questions, it's clear many patients know they have diabetes or hypertension. Some are supposed to be on medication but can't afford it. Comprehensive insurance could resolve the patient cost dilemma, Weder says. But the problems go beyond that.

Weder notices many of the patients who say they can't afford basic prescriptions — now carried by big discount chains for as little as $4 a month — have cigarettes in their shirt pockets that cost far more than the pills.

When Kevin D'Angelo, a dentist from upstate New York who's volunteered at more than 20 RAM expeditions, asks patients with the worst decay what they drink, the most common answer is Mountain Dew, often five or six cans a day. The only way to get teeth as bad as some of those he sees, D'Angelo says, is almost never to have brushed at all.

Many of those waiting for care stagger under too much weight. And while some speak glowingly of their regular physicians, many say they don't see the need for one. Still others recount the difficulty of getting in to see a doctor or a dentist in rural areas where providers and openings for people without insurance are in short supply.

For all the undeniable good RAM's volunteers do, there's only so much a weekend's barrage of free care can solve.

"I think to myself, is this how we should be delivering health care in this country?" says Lynne Lacey, a hygienist who's driven 12 hours from Binghamton, N.Y. to volunteer. "I'm doing something that I think is important, but is it the right way?"

It's like the little Dutch boy in the story of old who holds back a flood by sticking his finger in a dike, says Bruce Behringer, an expert on Appalachia's public health needs at East Tennessee State University.

RAM, he says, "is a symptom of the problems in the health care system, not a solution."

Hannah Hurst is back for Day 2.

Yesterday, RAM's dentists pulled 16 of her teeth. Now, after some much needed sleep, the Hursts are eighth in line. In the gym, Trey Parker, a dental student from the University of Louisville, welcomes her return to the chair.

But before reaching for his tools, Parker honors Hannah's request. With heads bowed, he links hands with Jack and two other volunteers, a circle completed by reaching down to Hannah's shoulders.

"Lord," Parker says, "let Hannah have the strength to bear through getting all her teeth pulled; that she can hold up; that her jaw will be made whole and that she can live a happier life being a mother. In the name of Jesus Christ."


Today is a bit of a gift. By 9 a.m., just 260 patients have come through the door.

Sundays can be a race for RAM. The doors close around noon, to allow for cleanup and to give tired volunteer doctors, many from out of state, time to get home. But today's smaller crowd means they may actually get to treat everybody.

Still, the morning present unexpected challenges.

In the hallway, Olesea Gaitur waits to see a doctor. Gaitur, an immigrant from Moldova, is expecting a baby in March, husband David explains. Tennessee pays for prenatal care. But, lately, when she stands up, she's been seeing black. TennCare doesn't cover that.

"If she's pregnant and blacking out she needs to go to the emergency room," Dr. Erin Bryant tells the couple. "I'm sorry about that. I wish we had an obstetrician here, but we don't."

But after a few more questions, Bryant reconsiders. Perhaps Olesea Gaitur is dehydrated. Volunteers lead her to the high school's cosmetology classroom, where — under the gaze of shelves full of styling mannequins — the doctor checks her blood pressure.

Out at the sign-in table, a family of three comes in seeking eye exams and glasses. But they're late, there's only one optometrist today and RAM is down to its last two registration forms.

"Then find one more form," Ron Brewer, RAM's Tennessee director tells a volunteer.

Once in, a long wait remains. At midmorning, patients still fill the bleachers and line the hallway, offering a case study in needs health care reform may not answer.

Take Hannah Hurst's teeth. Proposals by Congressional Democrats, while they would greatly expand traditional medical coverage, won't cover dental care, except for children.

It's no better for vision care, not covered for adults under either the House or Senate bills.

Many RAM patients have insurance with high deductibles that act as barriers to care. Reform would limit out-of-pocket costs. But the newly covered would still be left to pay about 30 percent — a cushion against catastrophe, but perhaps a discouragement for the working poor with more routine illnesses.

Changing the economics, though, is just the start.

"There's a culture that sort of surrounds the problem," Brock says.

All the high blood pressure readings in the cafeteria aren't a coincidence. Heart disease, hypertension and diabetes are serious problems throughout Appalachia. That is partly the result of smoking, lack of exercise, an unhealthy diet and obesity. But it also reflects attitudes and relationships with the health care system, Behringer says.

It can be hard reaching a doctor in thinly populated counties with few roads and mountains that make travel a challenge. Even when that's possible, many people don't see a doctor regularly and many doctors are unable to build the continuous relationships with patients to help ensure care, Behringer says.

The problems are all too real to Eddie Graham, the local school health coordinator, who lobbied RAM to come to Maynardville. He recounts the challenge of trying to foster health in an area where some parents can't read or write well enough to fill out applications for the public insurance that is available. Some families send their children to class sick and tell them to go see the school nurse. Kids arrive at elementary schools carrying chewing tobacco.

Making health care affordable only partly solves problems like these, he says.

"It's changing beliefs," Graham says. "It's educating people about what is health." ___

When the numbers are totaled, Expedition No. 587 into America's health care jungle will be recorded as followed:

Over 1 1/2 days in Maynardville, 701 patients have come through RAM's doors.

Its dentists have extracted 852 teeth and put fillings in 234 others; 345 pairs of eyes have been tested, and 335 pairs of glasses have been made; 87 people have been examined by a medical doctor.

If RAM was going to send out a bill for the weekend's services, it would total $138,370.

Does that make it a solution to a crisis or a symptom? The answer may lie beyond the bottom line.

When Brittney Prince goes back to school Monday, she'll be wearing her first pair of eyeglasses.

"Momma," she says, gazing out into the sunshine through lenses made by a volunteer, "the grass is not fuzzy any more."

And when Hannah Hurst — her toothless mouth stuffed with gauze — is helped from the chair, she hugs Trey Parker and Dr. Bill Collins. The swelling will take three months to heal and keep her on a liquid diet. At church, raising money for dentures may have to wait until spring. But, at last, her prayers have been heard.

"There is no other answer for it but God and it just makes me so much more thankful," she says. "It truly is my testimony now. You keep praying, you keep asking, and your answer will be there sooner or later."

1 comment:

  1. Healthcare inflation is a done in deal unless reforms can bring down costs